Baby Loss Awareness Week

Douglas Ross Excerpts

Thursday 19th October 2023 Commons Chamber

[Tim Loughton]

The hon. Lady gallops way ahead of me; I will come on to speak about that. That is what my private Member’s Bill, now an Act, seeks to address, so I will come back to those comments.

Stillbirths are not the only issue. Progress has been poor on neonatal death rates, which have plateaued for some years and are even further away from coming down to those 2025 targets. There were 1,719 neonatal deaths last year—that is deaths within 28 days of being born. There is also the whole subject of miscarriage. I will not go into great detail on that, but we know that at least one in five pregnancies end in miscarriage, and there are probably more that we do not know about. The Government have done a lot of good work on this. I pay tribute to the former Health and Social Care Secretary, now Chancellor of the Exchequer, for his emphasis on safety in hospitals, particularly safety around maternity, and for the launch of the Safer Care Maternity action plan back in 2016, which were all about improvements in maternity safety training. The Our Chance campaign was targeted at pregnant women and their families to raise awareness of symptoms that can lead to stillbirth.

The inauguration of bereavement suites in hospitals was another important development—I have seen my own in Worthing. It was wholly unsatisfactory that a woman, following a stillbirth, would be placed in a bed next to a mother who had fortunately had a healthy, screaming baby. The impact on the mother and the father of having a stillbirth and then seeing the reverse was traumatic and had to be dealt with. The bereavement suites provided a more discreet, private area, away from those mums lucky enough to have healthy babies.

[Douglas Ross]

I am grateful to my hon. Friend for giving way. It allows me the opportunity to welcome the fact that, last week, NHS Grampian announced the upgrading of the bereavement suite at Dr Gray’s Hospital. Marsha Dean from Elgin, one of two bereavement specialist midwives in the NHS Grampian area, welcomed that. Tina Megevand from Moray Sands said, “It’s so very important that anyone affected by pregnancy loss or death of a baby gets the best possible bereavement care and is offered a safe, protected space to spend time and make memories with their baby.” What my hon. Friend has just said is crucial and I just wanted to put on record our appreciation in Moray for having such a facility.

[Tim Loughton]

I am grateful to my hon. Friend for putting on record what his local hospital is doing, and I hope that that is happening around the country. Certainly, my own hospital takes great pride in its bereavement suites and they have made a big difference to the impact on parents in its maternity wing.

We have had the Ockenden report as well as the Cumberlege review, so there has been a lot of activity from the Department of Health and Social Care, but we need to go so much further. Although I will not go into detail here, I wish to reference the high incidence of stillbirths and baby loss among the black, Asian and minority ethnic community, who are something like five times less likely to receive maternal aftercare.

As hon. Members have mentioned, there are also real challenges and big vacancies in the midwifery workforce. As has been said, 38% of maternity services have been rated as requiring improvements in safety, so there is still a long way to go. One thing that has particularly alarmed me—I am sure other hon. Members will have had the briefing from that excellent charity, Sands—is the state of perinatal pathology. I think my hon. Friend the Member for Truro and Falmouth (Cherilyn Mackrory) may be talking further on that. Currently, there is a significant proportion of parents who have to wait more than three to six months for their babies’ post mortem to be undertaken and for the results to be communicated to them. Those waiting times are then further exacerbated by poor communications about what is happening. Having gone through the trauma of losing a newborn baby, parents then have to wait a long time to find out what happened, which causes them additional trauma.

As I mentioned earlier, there is the whole issue of mental illness and, in particular, the impact of mental illness and depression and the prevalence among teenage mothers. It is important that we deal with that early and that the support is there because we know—the Minister mentioned this in the previous debate—about the high incidence of suicide linked to the perinatal period.

Therefore, this is an important subject. Good work has been done. The Government have good plans, but there is still a lot of work to do before we can genuinely say that this is a very safe country in which to give birth and we rank with the top countries across the rest of Europe.

I wish to talk about my excellent private Member’s Act, which passed through Parliament some time ago. Madam Deputy Speaker, you will not be surprised to hear me mention it again because I have raised it on the Floor of the House many times. I have harangued the Minister about it many times and will continue to do so.

My Civil Partnerships, Marriages and Deaths (Registration etc.) Act 2019 passed through its final stages in this House on 15 March 2019. It received Royal Assent on 26 March 2019; that is 1,303 days ago. It did four things. First, it enabled opposite sex couples to have a civil partnership. That became law on new year’s eve 2019. On that day, 167 couples availed themselves of that opportunity and many thousands have since, so we can tick that box. A second part of the Act enabled for the first time the names of mothers to be included on marriage certificates. Up until then, they did not exist, which particularly added insult to injury if it was the mother who brought up the child who was getting married and the father, whose name does appear, had never been on the scene at all. That at last was reversed with my Act—another tick.

Another part of the Act mandated the Secretary of State for Health and Social Care to produce a pregnancy loss review. A committee was set up—I sat on that committee —and in July this year the independent pregnancy loss review, which contained many recommendations—there were some good things in it, even though it had not met since 2018—was at last published, so another tick.

The fourth part of my Act was on coroners’ investigations into stillbirths. What was agreed by this House unanimously, with Government support, following much scrutiny in the other place as well, was that the Secretary of State must

“make arrangements for the preparation of a report on whether, and if so how, the law ought to be changed to enable or require coroners to investigate still-births”,

and that, after the report had been published, the Lord Chancellor may, by regulations, amend part 1 of the Coroners and Justice Act 2009. It was a very simple amendment to ensure that, in future, coroners had the power to investigate stillbirths. It did not require any more primary legislation. It required a one-line amendment to the Coroners and Justice Act.

When I made my speech for my private Member’s Bill on 15 March 2019, I could not have been more wrong. I said then that I knew that we were pushing at an open door with my last measure, as the Health Secretary had signalled his support for it at the Dispatch Box during a statement on stillbirths in November. I then set out the anomaly in the law where coroners in England have the power to investigate any unexplained death of any humans unless they are stillbirths. That is because a baby who dies during delivery is not legally considered to have lived. If the baby has not lived, it has not died and coroners can investigate deaths only where there is a body of a deceased person.

Most people agreed—certainly the coroners themselves, who strongly supported this—that that is an anomaly in the law. Given some of the scandals that I will come to in a minute, it has given rise to a suspicion—this is the point that the hon. Member for North Ayrshire and Arran (Patricia Gibson) raised—that some stillbirths that went unexplained might have been avoidable, and were mistakenly registered as stillbirths because that effectively excluded the coroner from launching a further investigation. My Bill was therefore simple in its aim.

A consultation was launched, actually before my Bill became an Act, because the Secretary of State was so supportive of it and saw it as a formality. The consultation on the changes closed on 18 June 2019—over four years ago—and has still not been published. In order for new regulations to come in, the consultation and subsequent proposals have to be published, but we still have not got over the first bar of publishing the consultation. I have frequently queried when the Government will publish the consultation, and have frequently received a barrage of excuses. Of course, covid was the first excuse for why the consultation results—not even the proposals—could not be published.

The matter was chased up by the Justice Committee, which produced its own report on coroners and reinforced the need to get on with the measures in my Act. That message was reinforced by the Health and Social Care Committee, which also produced a report to say that the Government needed to get on with the measures. Today’s Minister, for whom I have a lot of time, as my near neighbour in Lewes, has written to me several times. One of the excuses was that we needed to wait for the Health and Care Act 2022 to go through in the last Session because of various considerations that could have an impact. That Act passed last year, so is not a consideration anymore.

We then had to get the pregnancy loss review published, for which we had waited since 2019. That has now been published, as I have said. We then had the further excuse that the Ministry of Justice was dragging its feet. The problem is that it is a Department of Health and a Ministry of Justice issue. I have tackled the Minister for Justice on several occasions. I asked for a joint meeting with the Minister for Health and the Minister for Justice. That meeting was cancelled six times, until it eventually happened on 21 March this year, when I was told that everything was in hand and being sorted out. I raised the matter again in Justice questions on 12 September. I was told:

“Both the Health Minister and I are pushing this as fast as we possibly can.”—[Official Report, 12 September 2023; Vol. 737, c. 766.]

This is appalling. Madam Deputy Speaker, you and I have been in this House for an equally long time. I cannot remember a piece of legislation waiting to be enacted for as long as this, particularly when there appear to be no objections to it. It has been passed unanimously and is not contentious; the coroners want to do it. It is absolutely extraordinary. I will take this opportunity to put it out in the open yet again that the Government need to get on with this. The legislation is even more important now than when it was passed in 2019, and when I produced it as a private Member’s Bill in 2017.

Four things needed to be resolved about how coroners would look at these matters, and they have all been resolved. First, we all agreed that they should look only at full-term stillbirths. That is where a stillbirth is least likely to happen, and therefore more questions arise. I think that everybody agreed on that. Secondly, it should be at the discretion of the coroner. The coroner will certainly not want to look at every single stillbirth, but where questions are raised by the parent or others that something has gone a bit awry and we need more information, the coroner can decide at his or her discretion whether there is a case for further investigation. We are talking about dozens, or scores, of cases, not hundreds or thousands.

Thirdly, it will be up to the coroner to decide, even if the parents do not want a review. That was a difficult one, but there is evidence that some stillbirths can be brought on by domestic violence during pregnancy, and obviously there may be a cover-up because a mum is being coerced. It is right that there should not be a veto and it should be down to the coroner to decide. Fourthly, the coroners have decided that it is not a significant resource issue. We do not need to train up a fleet of specialist coroners; they always want more money, but they think that they can simply take on the responsibility. All those things have been resolved. There are no outstanding questions, but as I said the need for the legislation has grown since it went through.

I do not need to remind everybody about the various scandals that have happened. The Nottingham maternity review currently under way covers the latest of those revelations. It will be the UK’s largest maternity review, with 1,266 families having already contacted the review team with their concerns. The Shrewsbury and Telford Hospital NHS Trust review, which has already been mentioned, of the deaths of more than 200 babies and nine mothers between 2000 and 2019, found that 201 babies could or would have survived had the trust provided better care, and that families were wrongly blamed when their babies died, were locked out of inquiries into what happened, and were treated without compassion and kindness.

The Morecambe Bay review in 2015 found unnecessary deaths of 11 babies and one mother between 2004 and 2013 due to oxygen shortages, mismanaged labour, failure to recognise complications, and so on. When the East Kent review was published, the headline was that the East Kent Hospitals University NHS Foundation Trust was logging baby deaths as stillbirths when in fact they were not stillbirths. What would the reason for that be? Potentially a cover-up, so that a further investigation by a coroner could not take place.

The East Kent review into the ongoing problems with the trust was described as harrowing, with more than 80 concerns about midwives and nurses working at the trust investigated by the regulators since 2015, including cases involving the police. Eleven midwives and nurses from the trust have been struck off, suspended or placed under conditions in relation to such cases, and 64 doctors from the hospital have been subject to investigation by the General Medical Council over the last decade, with three struck off and three suspended. The report showed a failure to implement the recommendations of earlier reports, allowing failings to continue at East Kent, and at other hospitals elsewhere in the country.

It needs reinforcing that most nurses, midwives and doctors do a fantastic job in difficult circumstances. They most of all will want to ensure that incompetence by a few, and potential cover-up, do not effectively undermine the reputation of those working in maternity care across the whole country.